Where a spiritual descendant of Sir William Osler and Abbie Hoffman holds forth on issues of medicine, media and politics. Mostly.

Thursday, January 22, 2009

Drug Company Funding of CME--Notes from the Family Fight

Over at Medscape (membership required), the white-coated brotherhood and sisterhood is talking about drug company funding of Continuing Medical Education--or "CME," as it's more commonly called, and as I predicted it ain't altogether pretty. This week they hosted a roundtable discussion entitled "Should We Eliminate Pharmaceutical Funding of CME?" and the comments, though small in number, shine a light on what I find a disturbing problem.

CME is the nationally-mandated method by which physicians keep themselves abreast of ongoing developments in their respective fields. CME can take the form of weekly local conferences such as Grand Rounds, or can include week-long seminars, symposia, conferences and whatnot. The length of each of these educational activities is commensurate with the number of CME credits, and each state has a specific number of CME credits that docs must accrue in order to be in good standing with their respective licensing boards.

Makes sense, yes? After all, you would want an infectious disease practitioner who finished fellowship in the early 80's, well before there was any treatment for HIV infection, to have learned something about the most important infectious disease in the US since finishing formal training, right? Especially in a field that changes as rapidly as medicine, where it is often said that half of what is currently known will be outdated or totally overhauled in about ten years, the need to stay current can literally make the difference between life and death.

So who would you want in charge of ensuring this education? You would think that professional societies, without any affiliations to for-profit companies, would arrange and direct the overwhelming majority of CME activities, but it just ain't so. As of 2001, drug companies paid over sixty percent of the costs of CME, and it does not appear the number is dramatically declining. Let's just pause to appreciate that for a moment: the groups that stand to benefit the most by altering the prescription habits of physicians are the very groups who sponsor the majority of educational activities for physicians in the US. Um, foxes guarding the henhouse, anyone?

How then, does a profession with a high sense of commitment to serve its patients find this arrangement acceptable? How can they not see the potential for conflict-of-interest, even if the corporations that sponsor educational activities have only the purest of intentions?

I have a couple of thoughts on the matter but let's get back to the MedscapeRoundtable. Medscape chose to invite four physicians to write about the matter. Each of the statements were brief (about 4-6 paragraphs each), and two of the writers were essentially in favor of ongoing pharmaceutical funding, while two were essentially against it. Three of the four appear to be private-practice physicians (a hospitalist and two family docs), while one has an academic affiliation as a full Professor of Medicine. One of the four (who wrote in favor of drug company funding) served as a sometime speaker for a drug company, while the other three had no reported financial conflicts of interest. None of the four appear to have any expertise in the matter, at least by what Medscape reported about them. Doctor Rubin has no particular problem with non-expert physicians airing their thoughts on medical matters--he is one such non-expert doing so right now--but he does have a problem when the authors are leading a roundtable discussion on a website read by thousands of physicians around the country. Can I huff and puff in my blog? Sure. But I might not be the best person to speak with authority in a more formal setting, unless I had done a good deal of homework beforehand.

And it's quite clear from reading the posts that nobody had done a great deal of homework, pro or con. Doc Rubin's personal favorite entry was from a private-practice physician in Arkansas whose bluster far exceeded his thoughtfulness. Before attempting to summarize said doctor's piece, I note that it's easy to get heated in such discussions and Doctor Rubin frowns on the kind of name-calling in which this physician engages out of the starting blocks. I would never, for instance, even dream of calling such a person a "chucklehead" for his poorly-reasoned, highly polemic rant. Wouldn't dream of it.

The Arkansas Doc starts out noting, fairly enough, that lifelong learning is the responsibility of the doctor, and that we as physicians are the best-suited to determine our own educational needs. Then comes the whammy:

The opportunities for continued learning are now better than ever due to the development of the Internet. Unfortunately, there is a movement afoot to limit those options. A growing McCarthyesque purge seeks to restrict our educational choices by banning industry support of continuing medical education (CME).

"McCarthyesque purge"?! Under the category-heading for inappropriate allusions, Doctor Rubin thinks that this statement may likely not be supplanted from its perch for the remainder of 2009. He would point out in detail the foolishness of the historical comparison, but prefers to think it speaks for itself and he has other fish to fry forthwith.

The remainder of his arguments go like this:a. Because of the heavy money involved in CME, options for CME without such funding would be "severly limited," leading to situations where "nearly all high-quality educational conventions sponsored by professional societies would cease to exist."b. There's just no evidence that it influences physician behavior in ways beneficial to drug companies!c. Physicians just aren't that credulous!

With respect to his first point, that high-quality education would just disappear, does this imply that, without planning and forethought, it would be simply impossible to have professional gatherings? Billy thinks not, remembering his days at a conference while in graduate school in English lit, of no interest to any corporate sponsor of anything, and enjoying himself thoroughly at the decidedly-not-posh conference held on university grounds. Must physicians be forced to endure such sacrifices in the name of their profession? Billy thinks it will still be a step up from an English department conference, but yes, it must be so. It doesn't mean that educational activities have to grind to a halt, it just means that you might not be able to attend the next conference at the Ritz-Carlton, charming though such digs are.

As for there being no evidence that industry-sponsored CME results in no bias, Doctor Rubin finds this argument to be particularly rich. The evidence he cites is from the Accreditation Council for CME--the very body which has handed itself over to the industry funding in the first place! It's like asking Alberto Gonzales to investigate the Bush administration: not too likely you're going to get an impartial review. Any attempt at knocking down the argument about industry sponsorship of CME without at least mentioning Marcia Angell's must-read The Truth About Drug Companies (material on CME pages 138-141 for the google-booker's out there), Jerome Kassirer'sOn The Take, or even the milder tome by Jerry Avorn, Powerful Medicines--to say nothing of actually refuting their ample evidence--has not done due diligence. Mind you, this is Medscape's attempt at a serious discussion! You might as well invite Paula Abdul to air her opinions on the matter.

His last point, one that Doctor Rubin hears time and time again when he chooses to discuss this matter with various colleagues (though truth be told he has learned which colleagues are like-minded on this matter, and tends to avoid the remainder lest he lose his control in public), is perhaps the most precious of all: I'm not biased! Maybe everyone else is, but not...incredibly smart, skeptical me! The beauty of this argument is that one can smugly dismiss with the wave of a hand all the evidence that suggests that doctors as a group are in fact heavily biased by the industry tampering with CME (to say nothing of marketing), because one can just imply that it's those other docs who are unwitting dupes. And believe me when I tell you that this argument is the ultimate fallback. "IF you are 'dumb' enough to be indoctrinated by a drug rep with a bachelors degree then I AGREE you should not attend," says one MD in the ensuing discussion on Medscape. Skepticism? The skepticism of many physicians appears to be in force about everything except their opinions of their own, remarkable, infallible, skepticism.

Oddly--well, actually, not oddly at all--the real argument running beneath these rationalizations is virtually never spoken of. It's pretty simple, actually, and Doctor Rubin, despite his immense respect and affection for the vast majority of his colleagues, has heard that silent-yet-powerful argument since his early days in med school. The "argument," such as it is, is this: I am a physician and that entitles me to nice things. Trinkets, such as free horsd'oeuvres at the cocktail hour following the day's professional meetings, fancy dinners on the tab of the local drug rep, tax-deductible trips to "educational conferences" in the Bahamas--all this is part of the trappings of the lifestyle of a doc. Such is the mentality that resists seeing the obvious conflict-of-interest in industry sponsorship of CME; the defense of the indefensible rests on an emotional response, not a rational one. Until that mentality, that sense of entitlement changes, you can count on organized physician opposition to the meek suggestion that, you know, perhaps we might want to reconsider our relationship with groups whose job it is to make money, given that our job is theoretically to heal patients.--br

I, for one, am trying to bring medical education back to the realm of pure education. I run a medical news blog called InteractMD.com. The idea is that doctors and patients should get the medical news from doctors, not drug companies or journalists.

Oncology is one of the more frequent offenders, sad to say, when it comes to conflict of interest. I don't see drug reps, but the influence comes in subtler forms, like "journal articles" written by ghostwriters, and biased studies that ask the wrong questions.

The AMA is in bed with industry as well--they sell our prescribing data to the drug companies. This is why the drug reps have such detailed information on our prescribing practices.

I hope to see more and more grassroots rejection of the current medical "education" paradigm that has evolved around the industry's best interests.

Thank you, interactMD and therapyfirst! It is most encouraging to know that there are actually people, um, reading this blog.

As I was writing this entry I wondered about Medscape itself, which like so many other parts of medicine is very much tied into Big Pharma, on which it depends for sponsorship. On the one hand, I like Medscape for its design, for their video feeds, for the fact that it's got a huge readership, on the order of 100,000. On the other hand, like CME it is hard to ferret out the potential bias introduced by corporate underwriting. Curious to hear your thoughts on this.

I'm also here via Dr Carlat's blog (and have one of my own where I periodically take up this topic). Nicely written. I would add that physician entitlement ("I deserve fine things") is fundamentally the same dynamic as, "I'm not biased even if others are." Call it hubris or narcissism... I've heard pharma reps themselves imply that any doc worried about being biased by industry pitches must be insecure and weak-willed. It's almost a schoolyard dare: Are you man enough? Only with the maturity to see ourselves as fallible humans can we get past this, and focus on treating our patients instead of our egos.

You may or may not be interested to know that Howard Brody* speaks a great deal about the culture of entitlement among physicians in his book ("Hooked"). He too seems to think that it is at the social and cultural core of what drives much physician behavior as to COIs.

Great post, BTW.

*Full Disclosure: Dr. Brody is a professor and mentor of mine, and a member of my dissertation committee at UTMB (my dissertation is not on COIs, though I do work on the subject). I receive nothing whatsoever for mentioning his book here.

I arrived via Dr. Carlat’s blog as well. The Medscape article critiqued here would not have survived editorial review by the Medscape Nursing editors, in my opinion. Physicians, have you written to the editorial director of the Medscape Internal Medicine Web site to request that the article be removed from the site? If not, here is the editor’s contact information:

Nancy,You’re joking, right? The Roundtable articles are opinion pieces, nothing more, with every effort made to accommodate opposing views. So, on what basis would you have the article removed? That it doesn’t express the “correct” opinion?

R.W.,You may be surprised to learn that even Op-Ed pieces—in reputable publications—are checked for accuracy. If you need more information on this topic, look here: http://www.nytimes.com/2005/07/31/opinion/31shipley.html?pagewanted=1

Check out this “Roundtable” article:http://www.medscape.com/viewarticle/506101

Your comment "would not have survived editorial review by the Medscape Nursing editors, in my opinion." is interesting. I'm not sure I understand what you mean. Are you disparaging nurses? Indirectly insulting a profession so closely allied to physicians, seems to me, to be an example of the culture of entitlement mentioned earlier in this blog.

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About Me

I'm a physician and an educator with a clinical focus in infectious disease. I teach the spectrum from 3rd year medical students through senior ID fellows, and try to keep everyone loose when doing so. Whether I succeed or not, you'll have to ask them.
I am interested in issues where medicine intersects with politics, as well as how medical research is portrayed by media. In some ways my views are very much at the fringe of the rest of the physician community, although in several other critical ways I’m your typical stethoscope-wielding, white-coat-wearing, reflex-hammer-tapping doc and consider myself steeped in the traditions of the brotherhood and sisterhood.